DEPARTMENT  OF  HEALTH 

OF    THE 

CITY    OF    NEW    YORK 


REPRINT    SERIES 


JANUARY,  1916 


HEALTH    ASPECTS    OF    SCHOOL 
LUNCHES 


BY 

EDWARD     F.     BROWN 

Executive  Secretary,  New  York  School  Lunch  Committee.  Association  for  Improving  the 
Condition  of  the  Poor 

(SECOND      EDITTON) 


Public  health  is  purchasable.     Within  natural  limitations  a  community  can 
determine  its  own  death  rate 


DEPARTMENT    OF    HEALTH 

OF  THE 

CITY    OF    NEW    YORK 


DEPARTMENT  OF  HEALTH 

OF    THE 

CITY    OF    NEW    YORK 

NO.    26  REPRINT    SERIES  JANUARY,  1916 


HEALTH    ASPECTS    OF    SCHOOL 
LUNCHES 


BY 

EDWARD     F.     BROWN 

Executive  Secretary.  New  York  School  Lunch  Committee,  Association  for  Improving  the 
Condition   of  the  Poor 

(SECOND      EDITION) 


Public  health  is  purchasable.     Within  natural  limitations  a  community  can 
determine  its  own  death  rate 


BUREAU  OF  GOVERNMENTAL  RESEARO* 

LIBRARY 
44  LIBRARY  BUILDING 


HEALTH  ASPECTS  OF  SCHOOL  LUNCHES. 

By 

EDWARD  F.  BROWN, 

Executive  Secretary,  Nezv  York  School  Lunch  Committee, 
Association  for  Improving  the  Condition  of  the  Poor. 


I.    Food  and  Health. 

There  is  a  growing  recognition  on  the  part. of  the  medical  pro- 
fession of  the  value  of  the  prophylactic  uses  of  food.  Rosenau  has 
indicated  the  importance  of  the  relationship  between  diet  and  the 
prevention  and  treatment  of  tuberculosis,  diabetes,  nephritis;  arterio- 
sclerosis, gout,  rheumatic  affections,  other  disorders  of  metabolism, 
dyspepsia,  gastric  ulcer,  infantile  diarrhoea  and  many  other  dis- 
turbances. Unfortunately,  the  significance  of  the  relationship  is 
not  apparent  until  the  victim,  stricken  with  disease,  is  compelled 
to  restrict  or  alter  his  diet  to  adjust  the  body  to  its  normal  process. 
Given  improper  food,  man  ails,  degenerates  and  eventually  must 
succumb.  Food  education,  therefore,  especially  to  the  young,  is 
a  social  precaution  which  should  result  in  more  healthful  living, 
lessen  the  incident  of  sickness  and  lengthen  life. 

The  organized  feeding  of  school  children  recognizes  the  possi- 
bilities of  the  school  lunch  as  a  factor  in  the  public  health  propaganda- 
The  health  aspects  of  the  school  feeding  movement  are  varied,  and 
any  discussion  of  it  leads  us  to  consider  the  larger  problems  of  food 
and  how  it  affects  health.  We  give  here  a  summary  of  how  food 
may  disastrously  affect  health,  taking  the  admirable  material  col- 
lected by  Rosenau : 

1.  Some  foods  may  be  directly  poisonous ;  an  example  of  this  is 

seen  in  plants  which  contain  poisonous  alkaloids. 

2.  There  may  be  a  development  of  poisons  in  foods  as  a  result 

of  bacterial  contamination ;  an  example  of  this  is  sausage 
poisoning. 

3.  Foods  which  are  poisonous  because  of  adulterations,  such  as, 

from  the  addition  of  lead,  copper,  arsenic,  formaldehyde, 
sulphites,  etc.,  to  preserve  appearance  or  color,  or  to  alter 
taste. 

4.  Foods  containing  animal  parasites   such  as   trichina   and 

tapeworms.  These  infections  occur  usually  as  ante- 
mortem  infections  in  the  animal.  On  plant  life  infection 
may  be  carried  through  the  eggs  or  larvae  of  the  animal 
parasites. 


5.  Foods  containing  vegetable  parasites.     Pathogenic  bacteria 

are  not  infrequently  found  in  both  animal  and  vegetable 
foods.  They  are  more  frequent,  however,  in  animal 
foods. 

6.  Foods  may  also  contain  special  poisons,  such  as  ergot  in  rye 

or  solanin  in  sprouted  potatoes. 

7.  Food  may  be  inimical  to  health  where  it  is  taken  in  large 

quantities  or  where  certain  foods  are  ingested  without 

proper  balance. 
Excess  feeding  predisposes  to  fat,  and  not  infrequently  to 

arteriosclerosis  and  diseases  of  the  liver  and  kidneys.     On 

the  other  hand,  an  insufficient  quantity  may  result  in 

starvation. 
An  unvaried  diet  often  leads  to  disease.     This  is  particularly 

true  of  the  polished  rice  eaters  of  India,  who  are  known  to 

develop  beri-beri. 
The  absence  of   organic  acids  induces   scurvy;   impaired 

alimentation  often  results  in  rickets. 
Foods  which  are  highly  spiced  and  stimulating  irritate  the 

digestive  system  and  organs  of  excretion. 
In  children,  an  excess  of  food  produces  a  condition  resemb- 
ling acidosis. 

An  unbalanced  ration,  long  continued,  is  apt  to  be  harmful, 
tsuch  as  was  the  case  with  an  English  physician  who  had 

nourished  himself  with  sugar  alone  for  a  month,  as  a  result 

of  which  he  became  weak  and  shortly  thereafter  died. 
An  excess  of  protein  induces  gastro-intestinal  putrefactive 

changes,  with  danger  of  auto-intoxication. 
Indigestion  is  the  result,  frequently,  of  eating  when  the 

body  is  fatigued  or  when  mastication  is  impaired. 
A  dietetic  error  of  great  prevalence  is  the  lack  of  sufficient 

quantities  of  drinking  water. 
There  may  also  be  danger  in  foods  which  are  ingested  by 

persons  possessed  of  some  idiosyncrasy. 
Serious  defects,  and  common  ones,  also,  are  high  acidities 

and  low  mineral  contents  in  diets. 

II.    Early  Training  in  Food  Economy. 

During  the  plastic  and  responsive  period  of  a  child's  life,  the 
principles  of  correct  feeding  should  be  carefully  taught.  Dr.  Edward 
Huntington  Williams,  in  his  work  on  "  Increasing  Your  Mental 
Efficiency,"  says:  "If  the  child,  during  its  early  years,  has  been 
given  proper  training,  its  own  instincts  will  be  its  best  guide  in  the 
selection  of  proper  nourishment  later  in  life." 

The  lesson  is  best  taught  in  the  actual,  practical  preparation 
of  food  in  the  school.  The  advantage  of  early  training  in  school 
lies  in  the  fact  that  school  children  are  subjected  to  all  the  snares 
of  ignorance  and  incontinence.  The  frauds  perpetrated  on  them 
by  unscrupulous  vendors,  who  flash  highly  colored  candies  before 
their  innocent  eyes,  are  nothing  short  of  premeditated  poisoning. 

The  school  lunch  service,  therefore,  developed  to  its  fullest 
capacity  along  educational  and  social  lines — 


1.  Provides  food  for  children  at  school,  preventing 

(a)  Hurried  ingestion  of  food  at  home. 

(b)  Going  to  arid  from  school  in  intemperate  weather. 

2.  Guards  the  food  supply  of  those  children,  who,  unable  to  go 

home,  are  otherwise  compelled  to 

(a)  Buy  food  from  pushcarts,  etc. 

(b)  Bring  a  dry  lunch  from  home. 

3.  Gives  splendid   opportunity  to  teach   school   children  the 

science  of   feeding,  including  the  purchase,   preparation 
and  hygiene  of  food. 

V 

III.    The  Genesis  of  School  Feeding. 

The  medical  profession  is  to  be  credited  with  initiating  and 
developing  the  movement  to  feed  children  at  school.  Its  beginning 
in  England,  for  instance,  can  be  traced  to  a  memorandum  issued 
by  the  Director  General  of  the  Army  Medical  Service  which  followed 
the  wholesale  rejections  of  recruits  for  military  duty  because  of  their 
physical  disability.  The  national  defense  was  endangered,  and  an 
inquiry  was  accordingly  made  into  the  causes.  The  Interdepart- 
mental Committee  on  Physical  Deterioration  reported  that  the 
reasons  for  this  condition,  which  required  the  lowering  of  the  stand- 
ards of  fitness,  were  destitution,  ignorance  and  parental  indifference 
— all  of  which  may  be  traced  back  to  poverty.  It  is  notable  that 
these  revelations  came  after  a  rapid  rise  of  industrialism  which  fol- 
lowed the  discovery  and  use  of  labor-saving  machinery.  This  at- 
tracted much  of  the  labor  to  the  mills,  created  the  system  of  child 
labor,  overwork  for  women  and  the  exploitation  of  men.  The  first 
fruit  of  this  system  was  poverty,  which  in  turn  produced  the  things 
which  caused  the  physical  decadence  of  the  yeomanry  of  old  Eng- 
land. The  children  were  being  reared  as  weaklings,  incapable  of 
resisting  disease  and  largely  impervious  to  education.  As  a  measure 
of  relief  for  this  deplorable  situation,  the  inquisitorial  council  rec- 
ommended a  school  lunch  service  where  needy  children  could  be  fed 
at  the  public  expense. 

Developing  as  a  relief  measure  in  England,  calculated  to  heal  a 
social  disease  in  an  advanced  stage,  it  is  not  strange  that,  profiting 
by  England's  neglect,  the  American  movement  should  have  developed 
along  the  lines  of  feeding  children  before  they  became  the  objects 
of  public  charity.  The  difference  between  the  two  systems  is  that 
the  English  is  a  relief  measure  open  to  the  necessitous  and  based 
on  repairing  damage  already  done,  while  the  American  is  preventive 
in  that  it  seeks  to  avoid  the  necessity  for  making  such  social  repairs. 
In  America,  characteristically  democratic,  the  food  is  sold  to 
all  children,  while  the  English  system  is  restricted  to  children  of 
poverty. 

IV.     Organized  School  Feeding  in  New  York. 

In  1907  the  New  York  public  was  aroused  by  the  alarming 
statements  which  appeared  in  public  print  that  thousands  of  children 
went  to  school  each  day  suffering  from  lack  of  food.  An  investigation 
was  made  and,  as  a  result  of  the  popular  interest,  there  was  organized 
the  New  York  School  Lunch  Committee,  the  purposes  of  which  are : 


1.  The  provision  of  nourishing  lunches  on  a  self -supporting 

basis  for  all  school  children. 

2.  Special  observation  of  children  whose  physical  condition  is 

such  as  to  give  evidence  of  lack  of  proper  nourishment  in 
order  to  determine  the  underlying  causes  by  a  study  of 
their  homes  and  environment.  An  extension  of  this  aim 
requires  that  these  selected  cases  be  followed  up  to  the 
end  that  the  proper  agency  may  be  apprised  and  appro- 
priate action  taken. 

3.  The  formation  of  special  classes  of  mothers  for  instruction 

in  the  proper  care  of  children,  especially  of  cases  of  poor 
nourishment. 

At  the  present  writing,  there  are  20  schools,  registering  32,000 
children,  where  the  penny-a-portion  service  hereinafter  described  is 
operated. 

The  need  for  such  a  community  service  was  naturally  most 
pressing  in,  the  districts  where  people  were  poor ;  where  mothers 
worked  in  the,  factory  by  day,  and  where  the  children  depended  for 
food  on  the  few  pennies  which  purchased  candy  from  the  vendors 
about  schoolhouses. 

An  experiment  was  tried  in  the  equipment  of  a  kitchen  in  a 
school  building,  where  soup,  sandwiches,  puddings  and  cocoa  were 
provided  at  the  rate  of  one  cent  a  portion — the  child  being  required 
to  first  purchase  a  bowl  of  hot  soup. 

Fundamentally,  the  service  is  devoid  of  any  mark  of  poor  relief. 
During  the  last  school  term  1,249,489  portions  of  food  were  sold, 
for  which  the  children  paid  $12,494.89.  In  supplying  nearly  a  million 
and  a  half  portions,  a  net  deficit  of  $4,624.52  was  incurred.  This  is 
equal  to  a  little  over  a  third  of  a  cent  per  portion,  and  was  paid 
from  funds  'entrusted  to  the  Department  of  Social  Welfare  of  the 
New  York  Association  for  Improving  the  Condition  of  the  Poor  by 
Mrs.  Elizabeth  Milbank  Anderson. 


V.    A  Guarded  Food  Supply. 

Naturally,  in  any  scheme  for  feeding  large  groups  of  children, 
where  the  prime  object  is  the  rearing  of  a  vigorous  race,  a  scientific 
basis  is  essential.  The  working  force  of  the  Committee  is  headed 
by  a  dietitian  who  is  responsible  for  the  character  of  the  food  and 
service.  The  principles  on  which  food  is  selected  are:  (1)  nourish- 
ment, (2)  palatability,  (3)  purity,  (4)  seasonability,  (5)  inoffensive- 
ness  to  racial  or  religious  preferences,  (6)  similarity  to  home  food, 
(7)  diet  balanced  according  to  food  principles. 

When  the  Committee  is  assured  that  the  food  meets  these 
requirements,  a  sample  order  of  the  raw  product  is  secured. 

VI.     Standardization  of  Foods. 

The  sample  is  then  submitted  to  three  tests:  (1)  chemical,  (2) 
bacteriological,  (3)  food  value. 

The  standards  set  provide  that  the  food  shall  be  chemically 
free  from  harmful  ingredients  and  contain  no  bacteria  likely  to 

'5 


result  in  injury.  It  is  not  enough  that  food  be  negatively  edible — 
it  must  meet  the  positive  test  of  food  value.  Somewhere  in  the  day's 
menu  there  must  be  provided  protein  to  supply  the  need  for  nitrogen ; 
carbohydrates  and  fat  to  generate  heat  and  energy ;  salts,  vegetables, 
acids  and  water  supply  to  mineral  matter  and  solvents  for 
metabolism. 

Co-operation  with  the  New  York  City  Health  Department  has 
brought  about  the  most  encouraging  results.  Analyses  have  been 
made  by  the  Department  and  by  the  laboratories  connected  with 
the  universities.  Moreover,  health  authorities  out  of  town  have 
always  aided  when  asked  to  inspect  the  manufactories  in  their 
communities. 

VII.    The  Hygiene  of  Food  Manufacture. 

When  there  is  every  sign  that  the  product  itself  is  pure,  the  place 
where  the  food  is  manufactured  is  inspected  to  ascertain  under  what 
conditions  the  food  is  made. 

Preference  in  purchasing  is  given  to  firms  where  the — 

1.  Bases  of  the  food  product  are  pure. 

2.  Handling  is  clean. 

3.  Manufacturing  establishment  is  hygienic. 

4.  Employees  are  examined  to  detect  their  possibilities  of 

transmitting  disease. 

5.  Standards  of  hours  and  wages  are  high. 

The  social  value  of  encouraging  trade  where  decent  conditions 
of  work  and  welfare  prevail  is  not  only  a  just  recognition  of  good 
public  service,  but  a  rebuke  to  the  unsocial  manufacturer  who  thrives 
on  adulterations,  overwork  and  underpay.  It  is  easy,  to  recognize 
here  another  measure  in  the  interest  of  public  health,  for  in  the 
degree  that  we  demand  and  secure  livable  conditions  of  labor  will 
we  secure  a  diminution  of  sickness,  incapacity  and  death. 

VIII.  The  Public  Service  Rendered  by  the  Cautious  Food  Purchase. 

Where  foods  are  found  to  contain  harmful  matter,  or  where  the 
conditions  of  manufacture  or  sale  are  unhygienic,  information  is  laid 
before  the  health  authorities  for  action.  This  usually  prevents  the 
further  distribution  of  a  product  which  is  likely  to  cause  injury.  In 
addition,  the  firm  is  notified  that  its  product  or  the  handling  of  the 
same  has  been  found  to  be  such  that  the  product  is  considered  unsafe 
for  feeding  to  children,  and  that  the  Committee  cannot  engage  in 
trade  with  it. 

There  is  an  educational  advantage  in  this  system  which  cannot 
be  overestimated.  Certainly  many  manufacturers  are  made,  in 
this  way,  to  realize  that  they  are  losing  trade,  and  this  tends  to1  make 
them  pay  more  attention  to  decent  handling  of  food  products. 
Sometimes  the  cause  of  complaint  is  merely  a  little  carelessness  in 
handling  at  the  factory  or  a  slight  infraction  of  the  law.  In  such 
cases  the  Health  Department  communicates  the  fact  to  us  and  also 
to  the  manufacturer.  This  results  in  a  clearing  up  of  the  cause  of 
the  complaint,  as  is  evidenced  by  the  subjoined  sample  correspond- 


ence,  which  is  typical.     From  the  Committee  to  the  Commissioner 
of  Health : 

"This  Committee  has  been  asked  to  purchase  candies  for 
the  penny  lunch  service  in  the  places  mentioned  below.  Before 
we  do  so,  I  should  like  to  ask  whether  it  would  be  possible  for 
you  to  assign  a  food  inspector  to  visit  these  places  and  let  us 
know  whether,  in  his  judgment,  the  premises  and  products  are 
of  such  a  character  that  we  may  feel  safe  in  purchasing  supplies 
there  for  the  children  of  the  schools/' 

From  the  Commissioner  of  Health  to  the  Committee : 

"In  further  answer  to  your  recent  communication  asking 
the  co-operation  of  this  Department  in  making  an  inspection 
of  certain  candy  manufactories  from  which  it  has  been  recom- 
mended that  you  purchase  candies  for  sale  in  the  'penny  lunch 
service,'  the  Commissioner  directs  me  to  inform  you  that  the 
reports  of  our  chemical  laboratory  show  in  each  instance  that 
poisonous  metals  are  not  found  to  be  present  and  the  candies 
are  therefore  considered  fit  for  human  consumption. 

"Inspections  have  been  made  by  our  Bureau  of  Food 
and  Drugs  with  the  purpose  of  securing  sanitary  conditions  in 
the  factories  of  the  concerns  named  in  your  communication. 
The  factories  of  the  *  *  *  companies  were  found  in  good 
sanitary  condition,  warranting  no  further  action  by  this  Depart- 
ment. The  factories  of  the  *  *  *  companies  were  found 
not  entirely  satisfactory,  and  notices  were  issued  by  this  Depart- 
ment requiring  a  correction  of  the  insanitary  conditions  found. 
Reinspections  disclosed  that  the  work  of  placing  these  establish- 
ments in  conformity  with  our  orders  is  in  progress,  and  it  is 
expected  that  they  will  meet  our  requirements  within  a  few 
days." 

IX.    Publicity  and  Purity  of  Foods. 

An  additional  precaution  taken  by  the  Committee  to  ensure 
the  purity  of  the  food  sold  in  its  school  lunch  service  consists  in 
carefully  scanning  the  lists  of  convicted  food  adulterers  prepared 
weekly  by  the  Health  Department.  Should  any  of  our  traders' 
names  appear  in  the  blacklist  business  dealings  with  them  would 
be  immediately  discontinued. 

X.    Hygiene  of  Equipment. 

It  is  of  the  utmost  importance  to  secure  sanitary  and  "filth 
proof"  kitchen  and  serving  equipment.  Unfortunately,  many  eat- 
ing utensils  are  constructed  along  aesthetic  rather  than  sanitary  lines. 
Cups,  bowls,  saucers,  spoons,  knives,  forks,  boilers,  etc.,  often 
contain  raised  lines  about  the  base  or  handles  which  serve  no  utili- 
tarian purpose,  but  are  placed  there  for  ornamentation.  These  are 
admirable  recesses  for  the  accumulation  of  food  particles  or  other 
material  which  sometimes  the  most  careful  washing  does  not  reach. 
The  planning  of  equipment,  construction,  storage  and  handling  offers 
splendid  opportunities  for  anyone  interested  in  protection  against 

7 


food  contamination.  All  this  naturally  inures  to  the  benefit  of  the 
children  in  at  least  two  distinct  ways: 

1.  It  removes  the  possibility  of  food  contamination. 

2.  By  suggestion  and  association  the  children  are  taught  to 

observe  hygienic  precautions. 

The  movement,  unfortunately,  has  not  as  yet  progressed  sufficiently 
to  have  the  kitchen  used  as  an  object  lesson  to  the  children.  These 
little  lessons  might  well  be  taught  as  a  part  of  the  child's  school 
education. 

XI.    Medical  Examination  of  Employees. 

In  order  to  prevent  any  possibility  of  disease  transmission  in 
the  preparation  and  handling  of  food,  the  Committee  asked  the 
Health  Department  to  make  a  thorough  medical  examination  of 
the  school  lunch  employees  to  ascertain  whether  they  were  free 
from  disease  and  were  not  disease  carriers.  Each  employee  sub- 
mitted to  a  complete  physical  examination  (body  naked),  and  the 
examination  included  throat  cultures  (diphtheria  bacilli)  and  blood 
tests  made  for  typhoid.  As  an  added  precaution,  facilities  for  free 
vaccination  against  smallpox  were  offered  to  each  employee  who 
had  not  been  vaccinated  within  the  past  three  years,  as  a  result  af 
which  two-thirds  of  the  employees  were  thus  immunized. 

In  addition,  100  children  who  assist  in  the  lunch  service  also 
submitted  to  a  special  examination  by  medical  inspectors.  We 
received  permission  from  the  Department  of  Health  and  the  Depart- 
ment of  Education  authorizing  the  medical  inspectors  to  make 
these  examinations  while  the  children  were  stripped  to  waistline. 
In  the  case  of  girls,  nurses  were  present  at  the  examination,  and 
the  examination  itself  was  made  by  women  physicians. 

In  all,  131  persons  were  examined,  of  whom  31  were  employees 
and  100  student  helpers.  A  striking  fact  is  the  almost  even  per- 
centage of  defects  found  in  the  two  classes  of  help,  employees  and 
pupils,  though,  on  the  whole,  the  records  of  the  employees  make 
the  better  health  showing.  The  two  most  serious  ailments,  pul- 
monary tuberculosis  and  syphilis,  were  disclosed  in  pupils,  there 
being  two  suspicious  cases  and  one  positive  of  the  first,  and  two 
suspicious  cases  of  the  latter.  Of  the  throat  cultures,  one  in  an 
employee  showed  diphtheria  bacilli.  Two  trachoma  cases  were 
found  among  the  pupils. 

Pediculosis  capitis,  so  common  in  the  school  population,  was 
found  in  10  per  cent,  of  either  group. 

Of  the  Widal  tests,  two  showed  positive  in  employees  and  one 
in  a  pupil.  The  figures  were  the  same  for  acute  bronchitis ;  chronic 
bronchitis  was  found  in  one  employee,  ringworm  in  one  pupil. 

The  result  demonstrates  very  clearly  that  the  examinations 
were  worth  while,  inasmuch  as  they  disclosed,  even  though  in  a  very 
small  percentage  of  cases,  a  situation  which  needed  attention.  Natu- 
rally the  recommendations  made  by  the  medical  inspectors  as  to  the 
disposition  of  those  employees  whom  it  was  found  unwise  to  continue 
were  immediately  followed,  and  in  the  case  of  school  children,  nurses 
have  visited  the  homes  and  had  the  children  treated  for  their 
condition. 


The  1914-1915  examinations  were  made  by  the  physicians  of 
the  Department  of  Education. 

XII.    Scientific  Feeding. 

The  strict  observance  of  dietetic  principles  is  a  real  justification 
of  the  school  lunch  service.  It  is  common  knowledge  that  the 
improper  selection  of  food  for  children  is  likely  to  leave  their  bodies 
undeveloped  or  an  organic  process  impaired. 

For  this  reason  it  is  of  the  utmost  importance  that  the  faod 
served  the  children  be  selected  and  prepared  on  a  wholly  scientific 
basis.  The  principle  on  which  school  feeding  is  founded  is  that  it 
implies  something  needful  to  the  child  which  the  home  for  some 
reason  has  failed  to  meet.  Chief  among  its  services  is  the  scientific 
nature  of  its  diet.  It  is  undoubtedly  true  that  many  housewives, 
particularly  among  the  poorer  classes  (where  there  has  been  little 
opportunity  to  learn)  are  unfamiliar  with  the  fundamental  principles 
of  feeding  and  the  function  and  use  of  food. 

In  many  households  foods  are  prepared,  among  other  reasons, 
because  they  (1)  require  little  labor;  (2)  satisfy  a  peculiar  taste; 
(3)  are  apparently  cheap.  These  considerations  do  not  cover  the 
balance  of  necessary  ingredients,  seasonability,  abundance  or  variety. 
Such  haphazard  feeding  sooner  or  later  culminates  in  illness,  and 
it  is  often  a  source  of  wonder  to  many  parents  why  their  offspring 
should  suffer  since  they  were  fed.  It  is  no  answer  to  such  a  condition 
that  children  should  be  fed  at  school.  The  wiser  course  would  be 
to  teach  mothers,  and  the  girls  who  are  to  be  the  mothers  of 
to-morrow,  how  and  what  to  feed  children.  Since  we  are  overrun 
with  housewives  who  neither  have  the  time  nor  the  inclination  to 
learn  how  and  what  to  cook,  we  must  guard  their  children  against 
a  similar  lack  of  knowledge.  This  the  school  lunch  does  admirably 
for  those  children  with  whom  it  comes  in  contact.  Here  the  foods 
are  chosen  to  build  up  the  worn-out  tissues  and  yield  the  energy  to 
enable  the  child  to  grow  and  learn. 

During  the  past  year  the  Committee,  in  co-operation  with 
Dr.  Frank  C.  Gebhart  of  Cornell  University,  subjected  all  the  foods 
served  by  the  Committee  to  laboratory  tests.  This  was  done  in 
order  to  measure  the  caloric  value  of  the  foods,  in  order  that  some 
standardization  might  be  effected.  Thus  it  is  planned  to  give  to 
a  child  between  400  and  500  calories  for  three  cents.  With  properly 
chosen  food,  the  child  may  secure  an  adequate  measure  of  nourish- 
ment for  an  expenditure  of  three  cents.  The  following  table  will 
show  the  caloric  value  of  the  foods  on  the  Committee's  dietary : 

Calories 
Soups — Half  pint  Per  Portion 

Green  Pea 128 

Cream  of  Barley 120 

Cream  of  Macaroni 113 

Lentil  112 

White  Bean  Ill 

Macaroni  and  Tomato 105 

Split  Pea 100 

Tapioca  and  Tomato 90 

9 


Calories 
Soups — Half -pint  Per  Portion 

Cora ." 90 

American  Vegetable 85 

Scotch   Broth    84 

Clam  Chowder 82 

Foods  Other  than  Soups 

Baked  Beans 167 

Baked  Macaroni  89 

Beet  Salad  57 

Potato  Salad 117 

Lentil  Salad 189 

Vegetable  Salad 76 

Butter  Sandwich 247 

Egg  Sandwich 236 

Jam  Sandwich 227 

Prune  Sandwich 243 

Cheese  Sandwich   250 

Pot  Cheese  Sandwich 212 

Apple  jelly  Sandwich 240 

Apple  Sauce 108 

Rice  Pudding 108  . 

Bread  Pudding   131 

Chocolate  Pudding 101 

Spice   Cakes    108 

Vanilla  Cakes   28 

Jelly  Tarts 83 

Prunes   180 

Dates  .  200 


Average 1 54 

The  calorie  aggregate  of  some  of  the  typical  trays  of  food 
purchased,  none  of  which  totaled  a  cost  of  mare  than  three  cents, 
are  shown  here : 

Green  Pea  Soup 128     Vegetable  Soup 85 

Bread,  Two  Slices 200      Egg  Sandwich 236 

Apple  Sauce 108      Rice  Pudding 108 

436  429 

Cream  of  Barley ...      120      Clam  Chowder   82 

Cheese  Sandwich 250      Butter  Sandwich 247 

Chocolate  Pudding 101      Jelly  Tart 83 

472  413 

Macaroni  and  Tomato.  .  .  .      105      Bean  Soup Ill 

Apple  Jelly  Sandwich.  ...     240     Bread,  Two  Slices 200 

Cocoa 100     Prunes 180 

445  491 
10 


XIII.    Food  Waste  and  Food  Education. 

Many  modern  food  customs  conduce  to  waste.  This  presses 
hardest  upon  the  poor  because  they  can  least  afford  it.  To  get  the 
maximum  good  from  food  requires  the  most  discriminating  selection. 
This  process  is  variously  performed  because  it  depends  on  individual 
initiative  and  requires  constant  attention.  If  we  could  have  each 
family  so  manage  its  dietary  as  to  get  the  maximum  energy  for  the 
minimum  cost,  much  of  the  widely  exploited  high  cost  of  living 
would  disappear. 

Foo'd  consumers  should  prefer  those  foods  whose  manufacture, 
advertising  and  sale  is  conducted  honestly.  Murlin  has  pointed  out 
that  if  each  manufacturer  were  compelled  to  state,  for  instance,  that 
"This  can  contains. . .  .calories,  of  which. . .  .per  cent,  are  proteins 
of  Grade  C,"  the  difficulty  would  be  overcome.  Of  course,  we  must 
do  something  more  than  merely  state  food  values  on  cartons  and 
cans.  We  must  educate  the  masses  as  to  the  meanings  of  these 
phrases  which  to  most  are  like  the  dead  languages.  These  can, 
however,  be  brought  home,  even  to  the  masses,  as  Dr.  Lusk  has 
pointed  out,  through  rational  educational  work. 

XIV.    Household  Standards  for  Food. 

In  the  average  household,  food  selection  is  a  matter  of  tradition, 
routine  and  unconcern ;  food  preparation  a  matter  of  family  custom, 
unscientific  knowledge,  haste ;  food  hygiene  a  lost,  or,  an  unacquired 
art.  Food  consumption  is  wasteful;  food  knowledge  is  meagre, 
unscientific. 

XV.     Economics  and  Health. 

It  has  often  been  pointed  out  that  health  is  in  direct  ratio  to 
the  economic  condition  of  the  population.  Trained  health  officers, 
therefore,  do  not  fail  to  insist  that  industrial  readjustments  are  the 
foundation  of  a  healthier  state.  To  mention  but  a  single  example, 
we  may  cite  the  admirable  report  on  infant  mortality  issued  by  Miss 
Lathrop,  which  shows  that  the  mortality  of  infants  is  in  inverse 
ratio  to  wages.  So  in  foo'd  problems,  it  is  necessary  to  teach  the 
ultimate  consumer  what  foods  are,  how  they  may  be  used  to  the 
greatest  advantage,  and  how  the  wisest  purchases  may  be  made. 
This  is  a  real  health  activity.  Organized  school  feeding,  through  a 
rational  educational  scheme,  offers  fruitful  possibilities  along  just 
these  lines. 

XVI.    Individual  Diets. 

The  school  feeding  movement  has  not  progressed  far  enough 
to  have  permitted  very  wide  experiments  in  the  individualization 
of  diets,  such  as  those  for  the  under-nourished,  the  anaemic,  the 
crippled,  etc.  Owing,  however,  to  the  cosmopolitan  character  of 
the  city  schools,  the  Committee  has  had  to  divide  the  dietary  into 
three  general  groups,  namely,  the  Italian,  the  Jewish  and  the  Ameri- 
can, corresponding  to  the  three  large  groups  of  children  within  our 

11 


city  schools.  For  the  Italian  children,  those  foods  which  are  usually 
to  be  found  in  Italian  homes  have  been  provided.  For  the  Jewish 
children,  it  has  been  necessary  to  provide  "kosher"  food,  inspected 
by  a  rabbi  and  complying  with  the  restrictions  of  the  Talmudic  co'de. 
The  American  children  have  been  served  with  dishes  which  are 
characteristically  American. 

At  the  present  time  there  are  ten  schools  in  which  the  kinder- 
garten children  and  those  of  the  classes  for  anaemic,  ungraded  and 
crippled  children  are  supplied  with  milk  and  crackers  in  the  middle 
of  the  morning.  It  has  been  the  aim  of  the  Committee  to  extend 
its  lunch  service  to  as  many  of  the  classes  for  cripples  as  possible. 
Moreover,  special  efforts  have  been  made  to  reach  the  tuberculosis 
cripples,  and  for  these  a  special  diet  has  been  arranged. 

XVII.    The  Uncontrolled  Food  Vendor. 

The  school  lunch  service  supplies  the  need  for  food  where  the 
home  has  failed  to  make  such  provision.  The  mothers  who  work 
out  by  day  frequently  make  a  practice  of  giving  the  child  a  few 
pennies  to  spend  for  lunch,  but,  which,  as  a  matter  of  fact,  the  child 
usually  spends  for  candies,  fruits  and  other  tid-bits.  The  push  cart 
and  basket  venders  of  candies,  cakes,  fruits  and  similar  foods  have 
from  time  immemorial  infested  school  neighborhoods,  selling  wares 
which  have  been  exposed  to  filth  and  dirt,  and  often  dangerously 
adulterated.  On  the  East  Side,  it  was  not  uncommon  to  find  cakes 
which  had  been  baked  in  tenement  homes,  sold  from  baskets  without 
covers,  and  carrying  dirt  and  filth  to  the  children.  Baskets  pf  can- 
dies, cakes  and  fruits  often  remain  in  the  homes  of  the  vendors  over 
night  without  proper  protection'  against  dust,  dirt,  flies,  roaches, 
filth  and  other  contamination. 

XVIII.    The  Menace  of  Malnutrition. 

An  examination  of  one-third  oi  the  school  population  in  New 
York  City  by  the  medical  inspectors  of  the  Health  Department  in 
1913  disclosed  13,999  cases  of  malnutrition.  On  the  assumption 
that  the  same  ratio  of  this  defect  is  to  be  found  in  the  unexamined 
two-thirds,  there  would  be  approximately  40,000  children  in  our 
schools  whose  health  is  impaired  owing  to  a  malnourished  system. 
Curiosity  has  led  the  author  to  inquire  into  the  subject  of  mal- 
nutrition in  other  cities.  Information  was  sought  from  41  of  the 
largest  American  cities,  but  the  reports  were  meagre  and  unsatis- 
factory. Only  15  of  the  cities  reported  the  number  of  children 
examined  and  the  number  found  malnourished.  The  information 
thus  obtained  is  as  follows : 

Children  Children 

Examined      Malnourished 

Cincinnati,  Ohio 36,438  1,619 

Chelsea,  Mass 2,766  98 

Haverhill,  Mass 7,976  152 

New  York,  N.  Y 330,179  13,999 

Providence,  R.  I -      3,021  359 

Rochester,  N.  Y 18,497  945 

12 


Children  Children 

Examined  Malnourished 

San  Francisco,  Cal 5,576  282 

Worcester,  Mass 18,342  389 

Springfield,  Mass 8,938  35 

Albany,  N.  Y 2,861  139 

Cleveland,  Ohio' .. . . .      61,578  671 

Harrisburg,  Pa 8,667  199 

Louisville,  Ky 13,190  59 

Newark,  N.  J 27,971  940 

Raleigh,  N.  C 1,909  133 


Total— 15  Cities 547,909  29,019  or  5.3% 

XIX.    Indications  of  Malnutrition. 

According  to  the  chief  medical  inspector  of  England,  the  indi- 
cations of  malnutrition  are  to  be  found  in  (1)  the  relation  between 
height  and  weight;  (2)  relation  between  height,  weight  and  age; 
(3)  general  appearance ;  (4)  skin  and  subcutaneous  tissue  conditions; 
(5)  muscle  tone  and  development ;  (6)  state  of  mucous  membrane; 
(7)  vigor  or  listlessness  which  may  appear  in  child's  facial  expres- 
sion; (8)  carriage;  (9)  movements;  (10)  voice;  (11)  interest;  (12) 
attention;  (13)  appetite. 


XX.     Cause  of  Malnutrition. 

The  causes  of  malnutrition  among  school  children  may  be  di- 
vided into  social  and  individual : 

I.  Social: 

a.  Living  in  rooms  without  windows  or  sunlight. 

b.  Lack  of  bathing  facilities. 

c.  Lack  of  ventilation. 

d.  Employment  out  of  school  hours. 

e.  Unsanitary  school  conditions. 

f.  Congenital  debility. 

II.  Individual : 

a.  Food  :  insufficiency,  unsuitability. 

b.  Injurious  sleeping  arrangements. 

c.  Insufficient  sleep. 

d.  Want  of  cleanliness. 

e.  Diseases  of — 

1.  Mouth. 

2.  Teeth. 

3.  Adenoids. 

4.  Bronchitis. 

5.  Tuberculosis. 

6.  Cardiac  diseases. 

7.  Rheumatism. 

8.  Post-exanthematous  debility. 

9.  Lack  of  childhood  care,  etc. 

13 


XXI.     The  Effect  of  Malnutrition. 

This  condition  may  be  due  to  any  of  the  causes  enumerated 
above,  which  in  turn  may  be  traced  to  other  causes.  These  may  be 
economic  pressure  on  the  family  budget;  ignorance  of  home  eco- 
nomics on  the  part  of  the  housewife ;  neglect  or  inability  to  feed  the 
family  properly ;  congenital  or  hereditary  diseases  or  defects  in  the 
parent  or  child.  Where  the  normal  condition  of  independence  of 
the  family  has  been  disturbed  by  death,  permanent  incapacitation  or 
disability  of  the  principal  breadwinner,  it  is  very  likely  that  the  first 
item  on  which  economy  is  practiced  is  the  table,  in  consequence  of 
which  the  growing  children  usually  suffer  most. 

The  principal  danger  of  malnutrition  is  a  reduction  in  the 
vitality  of  the  child,  thus  making  him  more  susceptible  to  disease. 
Further,  the  child  is  a  menace  to  his  classmates  in  that  he  can  more 
easily  become  a  carrier  of  infectious  disease  germs.  Pedagogically. 
it  is  well  known  that  the  educational  possibilities  of  a  malnourished 
child  are  always  at.  the  minimum.  He  lacks  alertness  and  it  is  diffi- 
cult for  him  to  pay  attention. 


XXII.    Prevention  and  Cure  of  Malnutrition. 

Malnutrition  may  be  prevented  by  the  proper  nourishment  of 
the  child,  both  at  home  and  at  school,  by  sufficient  periods  of  rest, 
pure  air,  sunlight  and  frequent  bathing.  Moreover,  the  school 
should  supply  the  lessons  which  might  be  taught  to  the  parent  as 
well  as  to  the  child  on  the  science  of  efficient  purchase  and  prepara- 
tion of  foods  for  family  use. 

Since  there  are  many  children  who  are  ill-nourished,  and  whose 
homes  are  not  likely  to  conduce  to  an  improvement  in  this  direction, 
it  is  certainly  desirable  to  inaugurate  the  service  of  hot  food  so  that 
these  children  may  not  be  deprived  of  the  means  wherewith  to  grow 
strong  because  their  parents  are  either  incapable  of  providing  the 
same,  or  are  indifferent  arid  neglectful. 


XXIII.    Education  and  Health. 

From  the  evidence  collected  by  the  Health  Department  it  would 
appear  probable  that  there  are  more  than  40,000  children  in  the 
public  schools  of  New  York  City  who  are  suffering  from  malnu- 
trition. While  it  is  true  that  there  are  no  standards  by  which  a  mal- 
nourished child  may  be  accurately  determined,  there  is  every  reason 
to  believe  that  even  this  estimate  is  too  low.  A  special  examination 
made  by  medical  inspectors  of  the  Bureau  of  Child  Hygiene  of  the 
Health  Department  within  the  past  two  months  in  two  schools 
showed  that  in  one  building,  housing  3,000  children,  650  were  mal- 
nourished ;  in  the  other,  with  a  register  of  3,757  children,  there  were 
401  malnourished. 

The  child  who  suffers  from  malnutrition,  regardless  of  what 
has  caused  this  abnormal  state,  is  very  poor  clay  to  mold.  Such 
children  are  usually  torpid,  irritable,  and,  when  they  are  not  imper- 

14 


vious  to  education,  are  backward  and  retard  the  progress  of  the  rest 
of  the  class.  It  can  hardly  be  doubted  that  the  expenditure  of  money 
on  the  education  of  a  child  in  this  condition  does  not  result  in  much 
benefit  either  to  the  child  or  the  state. 

The  condition  of  a  child's  body  is  dependent  on  food,  and  it  is 
essential  to  provide  him  with  the  most  nourishing  foods  in  adequate 
quantities  and  at  proper  times  if  we  wish  to  fit  him  to  meet  the  stern 
realities  of  life.  School  feeding,  however,  should  embrace  a  wider 
scope  than  supplying  a  single  meal. 

Various  experiments  tried  in  England  on  the  effects  of  the 
stoppage  of  school  meals  have  brought  about  some  very  interesting 
results.  In  Bradford,  for  instance,  during  the  Whitsuntide  holidays, 
no  meals  were  given.  When  the  children  were  weighed  on  their 
return  it  was  found  that  they  had  lost,  on  an  average,  one  pound, 
while  the  control  children  (those  who  had  not  received  school  meals 
before  the  holiday)  had  gained  an  average  of  one-half  pound.  It 
took  nearly  a  fortnight  to  make  up  for  the  holidays.  Similar  results 
were  shown  in  the  effect  of  the  summer  holidays.  The  control 
children  gained  on  an  average  thirteen  ounces  during  the  four 
weeks,  while  the  experiment  children  lost,  on  an  average,  one  pound. 

We  have  a  similar  example  of  this  in  the  Tuberculosis  Pre- 
ventorium  for  Children,  at  Farmingdale,  N.  J.  From  some  unpub- 
lished statistics  recently  compiled  by  the  Superintendent,  Miss  J. 
Palmer  Quimby,  it  is  learned  that  children  admitted  to  this  institu- 
tion almost  invariably  show  a  decided  increase  in  weight  during 
their  (4  months)  stay.  Where  children  have  been  discharged  at 
the  end  of  this  time,  and  have  subsequently  been  readmitted,  it  has 
often  been  found  that,  the  child's  weight  had  remained  stationary, 
even  during  a  period  as  long  as  a  year.  Almost  immediately  after 
readmission  a  second  marked  increase  in  weight  began. 

Although,  af  course,  a  number  of  factors,  such  as  poverty,  and  a 
lack  of  fresh  air,  are  responsible  for  this  failure  to  gain  in  weight  at 
home,  the  chief  reason  is  to  be  found  in  the  ignorance  of  parents 
in  constructing  a  proper  dietary  for  their  children. 


XXIV.     School  Feeding  and  Industrial  Disturbances. 

The  argument  has  often  been  advanced  that  the  feeding  of 
children  at  school  causes  shiftless  parents  to  shirk  their  just  share 
of  responsibility  in  the  nurture  of  their  offspring.  We  have  not 
found  this  so.  On  the  contrary,  our  employees,  coming  in  contact 
with  the  parents  in  the  districts,  are  often  consulted  regarding  what 
foods  to  prepare  for  children  at  home  and  how  to  prepare  them. 
In  New  York  City  the  school  lunch  service  is  utilized  chiefly  in  the 
districts  where  the  economic  condition  of  the  population  is  low. 
This  is  in  accordance  also  with  the  English  experience.  Thus  in 
1912  the  Pontypridd,  Merthyr-Tydfil,  Ilkeston  and  Neath  districts 
in  England  were  seriously  disturbed  by  an  extensive  coal  miners' 
strike.  As  soon  as  the  community  was  thrown  into  idleness  the 
need  for  school  lunches  became  very  pressing,  and  temporary  can- 
teens were  opened  throughout  the  districts. 


15 


XXV.     School  Feeding  a  Palliative  Social  Measure. 

The  need  for  a  school  lunch  system  ought  really  to  be  regarded 
as  a  symptom  of  a  serious  social  disorder.  The  necessity  for  the 
feeding  of  the  children  at  school  springs  usually  from : 

1.  A  demoralized  home  where  the  housewife 

(a)  works  out  to  supplement  a  meagre  wage. 

(b)  works  out  because  she  is  the  chief  bread-winner. 

2.  Indifference  of  the  housewife. 

3.  Ignorance  of  home  economics. 

The  service  of  a  noon  meal  under  the  circumstances  is  at  best  to 
be  considered  inadequate,  because — 

1.  Behind  each  child  in  need  of  such  a  service  is  a  home  which 

lacks  the  facilities  for  proper  feeding. 

2.  For  the  child  in  need  of  the  facilities  of  the  lunch  service 

the  need  is  just  as  great  for 

(a)  breakfast. 

(b)  supper. 

(c)  feeding  on  non-school  days. 

(d)  feeding  in  the  summer  recess. 

3.  If  there  are  children  of  pre-school  age  at  home  no  provision 

is  made  for  them  in  the  present  school  lunch  system. 

4.  For  the  mother  oi  such  a  home  nothing  is  done  to  make  it 

possible  for  her  to  feed  children  adequately  and  intelli- 
gently. 

5.  Any  desirable  effect  which  flows  from  the  scientific  feeding 

of  the  child  during  one  meal  time  at  school  is  very  likely 
to  be  destroyed  by  the  kind  of  food  the  child  eats  at  home 
during  the  other  meals. 

The  feeding  of  children  should  be  made  part  of  a  larger  social 
program  and  ought  to  be  considered  as  such.  Among  the  matters 
closely  connected,  the  following  deserve  consideration : 

Material  Considerations : 

1.  Adequate  wages  for  the  chief  bread-winner  of  the  family  to 

enable  him  to  permit  his  wife  to  stay  at  home  to  care  for 
the  children. 

2.  State   pensions   to   widows   with   children    of    school   age 

where  the  mother  has  no  other  means  of  support. 

3.  Abolition  of  manufacturing  in  homes  which  takes  the  atten- 

tion of  the  mother  from  home  duties. 

Educational  Considerations : 

Classes  to  teach  mothers  and  school  children  the  lessons  of 
(a)  food  selection,  (b)  food  purchase,  (c)  food  hygiene,  (d)  food 
preparation,  (e)  food  storage,  (f )  food  usage. 


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Pasteurization  to  Methods  and  Ap- 

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Control  of   Local   Milk  Local 

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REPRINT    SERIES 

(CONTINUED.) 

No.  18.  The  Next  Step  in  Preventive  Medicine.  By  S.  S.  Goldwater, 
M.D.,  Commissioner  of  Health. 

No.  19.  The  Use  of  a  Series  of  Vaccines  in  the  Prophylaxis  and 
Treatment  of  an  Epidemic  of  Pertussis.  By  Alfred  F.  Hess,  M.D. 

No.  20.    After  the  Sanatorium — What?    A  Symposium. 

No.  21.  Further  Development  of  the  Usefulness  of  the  Sanatorium.  By 
Charles  B.  Slade,  M.D.,  Visiting  Physician,  Otisville  Sanatorium. 

No.  22.  The  Health  Department's  Experience  with  Typhoid  Immuniza- 
tion. By  L.  I.  Harris,  M.D.,  and  Morris  L.  Ogan,  M.D. 

No.  23.  The  Viability  of  the  Typhoid  Bacillus  in  Sour  Cream.  By  Charles 
Krumwiede,  Jr.,  M.D.,  and  W.  Carey  Noble. 

No.  24.  The  Physical  Examination  of  the  Employees  of  the  Department 
of  Health  of  the  City  of  New  York.  By  Charles  B.  Slade,  M.D. 

No.  25.  The  Neglect  to  Provide  for  the  Infant  in  the  Antituberculosis 
Program.  By  Alfred  F.  Hess,  M.D.,  Visiting  Physician,  Willard 
Parker  Hospital. 

No.  26.  Health  Aspects  of  School  Lunches.  By  Edward  F.  Brown,  New 
York  School  Lunch  Committee. 

No.  27.  Causes  of  the  Loss  of  the  Cream  Line  on  Pasteurized  Milk.  By 
Charles  H.  Kilbourne. 

No.  28.  Puerperal  Septicaemia.  By  William  H.  Guilfoy,  M.D.,  Registrar 
of  Records. 

No.  29.  Dispensaries :  A  Growing  Factor  in  Curative  and  Preventive 
Medicine.  By  S.  S.  Goldwater,  M.D.,  Commissioner  of  Health. 

No.  30.     The  Role  of   Dairy   Inspection   in   San  Milk 

Supply.     By  Russell  Sturgis,  Chief,  Division  of  Milk  Inspection. 

No.  31.    Food  Regulations  of  the  Department  of  Health. 

No.  32.  Complement  Fixation  in  Pertussis.  By  Miriam  Olmstead,  M.A., 
and  P.  Luttinger,  M.D. 

'3.  Venereal  Diseases.  Their  Administrative  Control  as  Developed 
in  the  City  of  New  York.  By  Louis  Chargin,  M.D.,  Chief  of  the 
Division  of  Venereal  Diseases. 

Xo.  34.  The  Mosquito  as  a  Pest  and  as  a  Carrier  of  Malaria.  By  the 
Bureau  of  Preventable  Diseases  and  the  Sanitary  Bureau. 

No.  35.  Contagious  Diseases.  Their  Administrative  Control  in  Different 
Cities.  By  S.  Dane  Hubbard,  M.D.,  Chief,  Division  of  Con- 
tagious Diseases. 

.'•16.  A  Bacteriological  Study  of  an  Epidemic  of  Septic  Sore  Throat. 
By  Charles  Krumwiede,  Jr.,  and  Eugenia  Valentine  (from  Bureau 
of  Laboratories). 


The  department  will  enter  into  exchange  of  publications  with  public 
health,  medical  and  scientific  organizations,  societies,  laboratories,  journals 
and  authors.  Applications  for  publications  should  be  addressed  to  the 
Director,  Bureau  of  Public  Health  Education,  Department  of  Health, 
corner  Centre  and  Walker  Streets,  New  York  City. 


